Are clinical outcomes affected by type of plate used for management of mid-shaft clavicle fractures?

BACKGROUND: Open reduction and internal fixation (ORIF) using plate osteosynthesis for midshaft clavicle fractures is often complicated by the prominence of the implant due to the subcutaneous position of the clavicle. Reoperation rates for symptomatic clavicle plate removal have been reported to be as high as 53%. We sought to determine to which degree do clinical outcomes (all cause reoperation rate and rate of fracture union) differ between types of clavicle plates. MATERIALS AND METHODS: A retrospective chart review was performed using our hospital database for patients treated with ORIF for mid-shaft clavicle fractures (OTA/AO type 15-B). Implants included in this review were 2.7 mm reconstruction plates, 3.5 mm reconstruction plates, 3.5 mm precontoured clavicle plates and 3.5 mm locking compression plates. The primary outcome measure was the all cause reoperation rate. Secondary outcomes compared the rate fracture union, documented infection, hardware failures and clinical symptoms at the surgical site among the various plate types. Data was collected and descriptive statistics were analyzed. p values < 0.05 were considered statistically significant. RESULTS: A total of 102 midshaft clavicle fractures treated with ORIF were included in this study. The majority of patients were ≤ 50 years old (83.3%) and male (72.5%). The overall union rate for all plating constructs was 97.1%. We found that age, sex and smoking were not associated with the rate of re-operation. In addition, the fracture classification, type of implant used and number of screws used didn't increase the risk of revision surgery. In addition, more than 50% of patients complaining of pain at 6 weeks post-operatively required a second surgery for removal of hardware. Moreover, there was no association between age, sex, smoking, fracture classification or plate type and the rate of union. Interestingly, clavicle fractures fixed with 3.5 mm reconstruction plates were more likely to have hardware failure due to plastic deformation, whereas 2.7 mm plates were more likely to fail by plate breakage. CONCLUSION: Although different types of implants have different biomechanical properties, no difference in reoperation, union and plate removal rates were found between the various plate types. Future studies with a larger sample size are required to further examine these outcomes. LEVEL OF EVIDENCE: Level III.

Review of 5.5 Years' Experience Using E-mail-Based Telemedicine to Deliver Orthopedic Care to Remote Communities.

INTRODUCTION: The use of e-mail-based telemedicine has been demonstrated as an effective and low-cost way of delivering healthcare to patients in remote areas who have limited access to medical services. We established a novel teleorthopedic service for a catchment area encompassing 972,000 km2 using a commercial off-the-shelf e-mail application. Before the implementation of this program, patients with acute orthopedic injuries were required to travel by air up to 1,900 km for evaluation by an orthopedic surgeon. In the present study, we examined the patient demographics and consultation characteristics and calculated the cost savings associated with patient travel for this teleorthopedic service. METHODS: We retrospectively reviewed 1,000 consecutive e-mail-based consults and radiographic images received for new patients with acute orthopedic injuries from January 2008 to June 2013. Seventy-nine consults were excluded due to incomplete documentation, leaving 921 available for analysis. The service records were examined to identify patient demographics, orthopedic diagnosis, the percentage of patients managed locally, and the medical indications for patients requiring transfer. As the travel costs for patients requiring transport to the university hospital center are borne by governmental health agencies, the savings accrued from treating patients in their home communities were also calculated. RESULTS: For the 921 consultations, the mean age of patients was 27 years (range, 3 months-88 years), with 40.7% of all patients being younger than 18 years. The most common diagnoses were ankle fractures (15.2%), clavicle fractures (11.2%), distal radius fractures (11.2%), and fractures of the foot (10.2%). One hundred ninety patients (20.6%) required transfer, whereas 731 patients (79.4%) were treated in their home communities. Of the patients who were transferred, 123 (64.7%) required surgery, 55 (28.9%) required clinical evaluation by an orthopedic surgeon, and 12 (6.4%) required CT or MRI. Cost savings related to return trip travel expenses were calculated to be $5,538,120 Canadian (CAD) for the review period. SUMMARY: Using an e-mail-based teleorthopedic service to manage acutely injured patients in remote communities allowed 79% of patients to be treated locally, with travel-related cost savings of $5,538,120 CAD.

Metaphyseal tibial level (MTL) screws: a modified percutaneous technique for lateral plateau depression fractures.

INTRODUCTION: Lateral tibial plateau fractures are more frequent than medial fractures, and those with articular depression are particularly challenging because of high displacement risk. To prevent secondary subsidence, the gold standard is raft screws with a periarticular or anti-glide plate. Graft is used to fill the metaphyseal defect created by reduction in the depressed fragment. We present a case of Schatzker II fracture managed in a complete percutaneous fashion, with a new combined technique of raft screws and interference screw used as a support. CASE REPORT: A 51-year-old female sustained a Schatzker II tibial plateau fracture. Based on pre-operative CT, direction of reduction force to apply was drawn on coronal and sagittal cuts. OPERATIVE TECHNIQUE: Under fluoroscopic control, the split component of the fracture was reduced. The cortical window was then drilled in the lateral cortex, and a K wire advanced under the depressed fragment under fluoroscopic guidance. After fragment reduction with a bone impacter, internal fixation was completed by percutaneous introduction of two subchondral cortical screws. A bioabsorbable interference screw was then introduced in the impacter tunnel to support impacted bone under the reduced articular surface. Finally, a cortical screw was introduced, from anterior to posterior to prevent screw cut-out. CONCLUSION: The combination of subchondral screws in a jail technique with a bioabsorbable interference screw that we named metaphyseal tibia level (MTL) screw technique is, to our knowledge, not described. The MTL screw promises to be a true percutaneous reduction and fixation technique for Schatzker II and III fractures in patients with reasonable bone quality.

A pilot evaluation of the role of bracing in stable thoracolumbar burst fractures without neurological deficit.

STUDY DESIGN: Prospective, 2-center, observer-blinded, randomized controlled trial. OBJECTIVE: Investigate clinical and radiologic outcomes of bracing versus no-bracing in the treatment of stable thoracolumbar burst fractures. SUMMARY OF BACKGROUND DATA: Management of thoracolumbar burst fractures depends upon clinical presentation of neurological deficit and radiographic features of fracture severity. Neurologically intact patients with mild deformity and biomechanical stability may be treated with conservative therapy. METHODS: Patients with stable (AO type A3), single level, thoracolumbar burst fractures between T12 and L2 with no neurological deficit were randomized to nonoperative treatment with a customized thoracolumbosacral orthosis (TLSO) or no-brace. Self-reported clinical outcomes of pain, disability, and health-related quality of life, and radiographic outcomes of kyphotic progression and loss of vertebral height, assessed by 2 independent reviewers blinded to treatment group, were measured at 6 months follow-up. RESULTS: Twenty-three consecutive eligible patients were included (TLSO: n=12; no-brace: n=11). There were no between-group differences regarding level of injury (P=0.75) and baseline spine geometry including fractional canal compromise (P=0.49), anterior loss of vertebral body height (P=0.28), and sagittal Cobb angle (P=0.13). In-hospital stay was significantly shorter in the no-brace group (mean: 2.8±3.0 d) compared with the TLSO group (mean: 6.3±2.1 d; P=0.004). At follow-up there were no differences in anterior loss of vertebral body height (TLSO: 12.5%±10.2% vs. no-brace: 11.9%±8.1%; P=0.88), kyphotic progression (TLSO: 5.3±4.4 degrees vs. no-brace 5.2±3.6 degrees; P=0.93), adverse events, or self-reported clinical outcomes. CONCLUSIONS: Neurologically intact patients with stable thoracolumbar burst fractures treated with or without bracing had similar radiographic and clinical outcomes at 6 months follow-up. The no-brace group had shorter in-hospital lengths of stay. Conservative therapy involving early mobilization without brace immobilization may be warranted. Further studies with a larger series of patients and longer follow-up are required for conclusive findings.

Continuous Compartment Pressure Monitoring Allows the Early Detection of Compartment Syndrome After Arterial Revascularization.

Compartment syndrome (CS) occurs in several clinical scenarios. Reperfusion injury and tissue swelling are common causes. This can occur after trauma but also is seen post revascularization of extremities. CS is a difficult diagnosis to make in a timely fashion that avoids permanent tissue damage. The treatment for CS is immediate fasciotomy, but fasciotomy is not a complication-free procedure. Previous care pathways usually resulted in fasciotomy being performed in a disproportionate number of normal legs. These false positives and prophylactic releases are costly to the health system because of protracted hospital stays and increased surgery numbers. The desirable tool for surgeons would be one that decreases false positives and negatives while ensuring a diagnosis in a timely fashion with true positives. A new technology that allows continuous pressure monitoring seems to be the best aid to make a diagnosis. We present our experience in decreasing the time to diagnosis in a CS case post revascularization despite the neurological blockade.

Efficacy of different fixation devices in maintaining an initial reduction for surgically managed distal radius fractures.

BACKGROUND: Fracture of the distal radius is a common injury. Many treatment options exist for the surgical management of extra-articular and intra-articular distal radius fractures. The best method of treatment for these fractures remains controversial. We sought to examine radiographic outcomes of patients treated with non-spanning external fixator (NSEF), open reduction and internal fixation (ORIF) with locking plates and screws or closed reduction and percutaneous pinning (CRPP) and compare their ability to maintain radiographic parameters over the initial 6-week postoperative period. METHODS: We performed a retrospective review of radiographs showing 211 distal radius fractures treated with NSEF, ORIF or CRPP. We examined the images for a variety of radiological parameters. Measurements were taken immediately postoperatively and at 6-week follow-up to determine whether there was any loss of reduction. RESULTS: Of the 211 fractures, 104 (49.3%) were type-A fractures, 12 (5.7%) were type-B fractures and 95 (45.0%) were type-C fractures. The 3 treatments maintained the reduction obtained at surgery until healing. The CRPP and ORIF treatments failed to maintain correction in ulnar variance for the 6-week period; however, only ORIF actually changed the ulnar variance from presurgical values. CONCLUSION: Treatment with ORIF for comminuted, intra-articular distal radius fractures produces good radiographic results with maintenance of surgical radiographic parameters, whereas NSEFand CRPP of less complex fractures also provide good results. This suggests that fracture-specific fixation with CRPP or NSEF are sufficient for certain distal radius fractures.

Augmented reality in orthopaedics: a systematic review and a window on future possibilities.

AIMS: Computer-based applications are increasingly being used by orthopaedic surgeons in their clinical practice. With the integration of technology in surgery, augmented reality (AR) may become an important tool for surgeons in the future. By superimposing a digital image on a user's view of the physical world, this technology shows great promise in orthopaedics. The aim of this review is to investigate the current and potential uses of AR in orthopaedics. MATERIALS AND METHODS: A systematic review of the PubMed, MEDLINE, and Embase databases up to January 2019 using the keywords 'orthopaedic' OR 'orthopedic AND augmented reality' was performed by two independent reviewers. RESULTS: A total of 41 publications were included after screening. Applications were divided by subspecialty: spine (n = 15), trauma (n = 16), arthroplasty (n = 3), oncology (n = 3), and sports (n = 4). Out of these, 12 were clinical in nature. AR-based technologies have a wide variety of applications, including direct visualization of radiological images by overlaying them on the patient and intraoperative guidance using preoperative plans projected onto real anatomy, enabling hands-free real-time access to operating room resources, and promoting telemedicine and education. CONCLUSION: There is an increasing interest in AR among orthopaedic surgeons. Although studies show similar or better outcomes with AR compared with traditional techniques, many challenges need to be addressed before this technology is ready for widespread use. Cite this article: Bone Joint J 2019;101-B:1479-1488.

Spontaneous spinal epidural hematoma management: a case series and literature review.

OBJECTIVE: Spontaneous spinal epidural hematoma (SSEH) manifests from blood accumulating in the epidural space, compressing the spinal cord and leading to acute neurological deficits. Standard therapy is decompressive laminectomy, although spontaneous recoveries have been reported. Sub-optimal therapeutic principles contribute to SSEH's 5.7% mortality-which patient will benefit from surgery remains unclear. This study aims to investigate parameters that affect SSEH's progression, outlining a best-practice therapeutic approach. MATERIALS AND METHODS: Literature review yielded 65 cases from 12 studies. Furthermore, 6 cases were presented from our institution. All data were analyzed under American Spinal Injury Association (ASIA) score guidelines. RESULTS: Fifty percent of SSEH patients do not fully recover. In all, 30% of patients who presented with an ASIA score of A did not improve with surgery, although every SSEH patient who presented at C or D improved. Spontaneous recovery is rare-only 23% of patients were treated conservatively. Seventy-three percent of those made a full recovery, as opposed to the 48% improvement in patients managed surgically. Thirty-three percent of patients managed conservatively had an initial score of A or B, all improving to a score of D or E without surgery. Regardless, conservative management tends toward low-risk presentations. Patients managed conservatively were three times as likely to have an initial score of D than their surgically managed counterparts. DISCUSSION: The degree of pre-operative neural deficit is a major prognostic factor. Conservative management has proven effective, although feasible only if spontaneous recovery is manifested. Decompressive laminectomy should continue to remain readily available, given the inverse correlation between operative interval and recovery.

Biomechanical comparison of a unique locking plate versus a standard plate for internal fixation of proximal humerus fractures in a cadaveric model.

BACKGROUND: Newer internal fixation devices with a locking mechanism between the plate and the screw have recently been released. The efficacy of these plates in the proximal humerus has yet to be fully described. There is a need to compare the biomechanical properties of efficacy of plate fixation with or without locking screws for surgery of two-part proximal humerus fractures. Multiple-plane locking plate and cloverleaf plate designs were tested to determine their ability to maintain fixation on the humeral head. METHODS: Eight matched pairs of cadaveric shoulders with 7-millimeter osteotomy defects at the surgical neck simulating two-part fractures of the proximal humerus were loaded to failure in thirty degrees of glenohumeral abduction. One side was repaired with a proximal humerus locking plate and the other with a cloverleaf plate. The rotator cuff musculature was then loaded via a servo-hydraulic testing machine under displacement control to simulate the deforming forces present in vivo. FINDINGS: The average maximum load to failure was greater in proximal humerus locking plates than in cloverleaf plates (876 versus 712; P=0.04). INTERPRETATION: In the cadaveric, two-part proximal humerus fracture model that was created, the locking plate displayed significantly greater holding power of the humeral head. Clinical relevance is unproven but may be manifested in vivo as improved early range of motion exercises and functional outcome.

Anatomical risks of using supra-acetabular screws in percutaneous internal fixation of the acetabulum and pelvis.

We conducted a study to determine whether a lag screw placed percutaneously at the level of the pelvic brim for treatment of iliac fracture risks injury to the lateral femoral cutaneous nerve (LFCN). A 4-mm Kirschner wire (K-wire) was placed percutaneously into each of 8 human cadaveric hemipelvises (4 pelvises) at the level of the pelvic brim to represent the path of screw placement. Under fluoroscopic guidance, each K-wire was advanced from the anteroinferior iliac spine toward the posterior iliac crest. Cadavers were dissected at study end. Proximity of the LFCN to the percutaneously inserted K-wire was the main outcome measured. In 4 of the 8 hemipelvises, the LFCN was disrupted; in 3 hemipelvises, it was within 4 mm of the K-wire; in the last hemipelvis, it was 23 mm away. LFCNs varied anatomically from 1 to 5 branches; disruptions occurred more in LFCNs with multiple branches than in those with 1 branch. The results suggest considerable risk for injury to the LFCN during percutaneous fixation of iliac and acetabular fractures using a percutaneous screw at the level of the pelvic brim.

Circumferential Casting of Distal Radius Fractures.

OBJECTIVES: To determine the prevalence and predictive factors for the early cast alteration (splitting, trimming, and complete replacement) in patients with distal radius fractures (DRFs) treated in circumferential cast. To determine whether performing early cast alterations affects the fracture alignment. DESIGN: Retrospective Cohort Study. SETTING: Level 1 Trauma Center. PATIENTS: All adult patients who presented with a DRF to a tertiary care hospital over a 3-year period. INTERVENTION: All DRFs without immediate surgical indications are initially treated with circumferential casts at this center. OUTCOME MEASUREMENTS: The following variables were analyzed: patient demographics, polytrauma at the time of injury, physician subspecialty performing reduction, and type of cast alteration. Radiographs were used to assess initial fracture characteristics and secondary displacement of reduction over time. Analysis was performed primarily to identify predictive variables for the early cast alteration and secondarily to determine the effect of these alterations on fracture alignment. RESULTS: 296 patients were included in the study. One of every 4-5 patients had their cast altered within the first 10 days of treatment. One of 3 polytrauma patients had their cast altered. No type of cast alteration was found to be significantly predictive of loss of fracture alignment at 2 or 6 weeks. CONCLUSIONS: Cast alteration is commonplace after casting of DRFs but is not associated with the loss of alignment. Patients with polytrauma may benefit from immediate cast splitting. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Finite Element Analysis and Biomechanical Comparison of Short Posterior Spinal Instrumentation with Divergent Bridge Construct versus Parallel Tension Band Construct for Thoracolumbar Spine Fractures.

The ideal treatment for unstable thoracolumbar fractures remains controversial with posterior reduction and stabilization, anterior reduction and stabilization, combined posterior and anterior reduction and stabilization, and even nonoperative management advocated. Short segment posterior osteosynthesis of these fractures has less comorbidities compared with the other operative approaches but settles into kyphosis over time. Biomechanical comparison of the divergent bridge construct versus the parallel tension band construct was performed for anteriorly destabilized T11-L1 spine segments using three different models: (1) finite element analysis (FEA), (2) a synthetic model, and (3) a human cadaveric model. Outcomes measured were construct stiffness and ultimate failure load. Our objective was to determine if the divergent pedicle screw bridge construct would provide more resistance to kyphotic deforming forces. All three modalities showed greater stiffness with the divergent bridge construct. The FEA calculated a stiffness of 21.6 N/m for the tension band construct versus 34.1 N/m for the divergent bridge construct. The synthetic model resulted in a mean stiffness of 17.3 N/m for parallel tension band versus 20.6 N/m for the divergent bridge (p = 0.03), whereas the cadaveric model had an average stiffness of 15.2 N/m in the parallel tension band compared with 18.4 N/m for the divergent bridge (p = 0.02). Ultimate failure load with the cadaveric model was found to be 622 N for the divergent bridge construct versus 419 N (p = 0.15) for the parallel tension band construct. This study confirms our clinical experience that the short posterior divergent bridge construct provides greater stiffness for the management of unstable thoracolumbar fractures.

Incorrect radiographic evaluation after vascularized bone grafting for scaphoid fracture or nonunion.

PURPOSE: The present study is a review of patients with scaphoid non-unions treated with a dorsal vascularized bone graft. The study highlights a subset of patients incorrectly diagnosed as graft failures. METHODS: A retrospective review of patients who received vascularized grafts for scaphoid nonunions was performed over a four-year period. The vascularized graft of choice for this group was the dorsal radial extensor compartment artery. RESULTS: Five patients from a scaphoid fracture group who were treated with vascularized grafts were diagnosed as being failures (average of five months). None of these patients had tenderness on palpation of the scaphoid, and they were scheduled for revised vascularized grafts. All patients at the time of surgery were found to have healed. These patients were treated with arthrolysis, resulting in healing and full range of motion. CONCLUSIONS: Scaphoid vascularized grafts may have a markedly delayed radiographic healing time. Reoperation to perform secondary vascularized procedures may result in unnecessary surgery. Early imaging following a scaphoid vascularized graft may be inaccurate and may demonstrate a continued nonunion.

An in vitro study on the effects of freezing, spine segment, repeat measurement, and individual cord properties on cord interstitial pressure.

STUDY DESIGN: In vitro study of the spinal cord tension and pressure relationships before and after thawing in 6 different spinal cord segment from 2 individual pigs. OBJECTIVES: To determine if frozen and thawed spinal cord segments had different tension/cord interstitial pressure(CIP) relationships to fresh spinal cord segments. In addition, we will determine if the cord level, individual cord properties, and repeated CIP measurements affect the tension/CIP relationships. SUMMARY OF BACKGROUND DATA: Spinal cord distraction is a known cause of spinal cord injury. Several articles published on the pathophysiology of the cord distraction injury suggest that the underlying mechanism of injury is a microvascular ischemic event. We have previously described an increase in CIP with spinal cord distraction, pressures average 23 mmHg at 1 kg loads. METHODS: Six cord segments harvested from 2 pigs contained cervical, thoracic, and lumbar segments, and underwent distraction using a series of 7 calibrated weights from 0 to 1000 g weight. The cords were measured at each level of distraction. The cords were then frozen at -20 degrees C for a period of 2 weeks, and then thawed and retested. Multiple linear regression was then performed. RESULTS: There was no difference between the fresh and the frozen-thawed cords; there was statistical difference between the 2 pigs (18 mmHg) (P < 0.001). There are differences between the cervical and the thoracic cord segments (P < 0.001), and between cervical and lumbar cord segments (P = 0.056). There is a significant relation between the tension applied and CIP. Repeated trials showed no drift with repeated measures. CONCLUSION: Freezing and thawing spinal cords has no effect on the CIP/tension curves. Cord interstitial pressure developed is dependant on cord tension, cord level, individual cord properties, but not on the number of repetitions carried out while testing the spinal cord.

Percutaneous insertion of a proximal humeral locking plate: an anatomic study.

This cadaveric study sought to evaluate the feasibility of applying a locking proximal humerus plate with a novel minimally invasive technique. A unique pre-contoured locking plate was placed on cadaveric proximal humeri through a described minimally invasive approach. Proximity of the plate and screws to the axillary nerve and their respective surgical tracks were quantified. Safe screw hole placement with respect to the axillary nerve was determined. Risk of entrapment of the nerve beneath the plate was evaluated. Three of the holes near the middle of the locking plate consistently intersected the course of the axillary nerve and were unsafe for percutaneous placement of the screws. The axillary nerve could be palpated during the course of surgery and easily protected from injury. No entrapment of the axillary nerve occurred using this minimally invasive technique. The screw-in locking guide cannot be used with this technique as it caused tenting of the axillary nerve. Placement of a locking proximal humerus plate via a minimally invasive lateral trans-deltoid approach is safe if the locking screws are limited to superior and inferior holes. This can be done safely without entrapment of the axillary beneath the plate. Plate fixation of proximal humerus fractures may now be more desirable with the use of this approach.

Harvesting local cylinder autograft from adjacent vertebral body for anterior lumbar interbody fusion: surgical technique, operative feasibility and preliminary clinical results.

Autogenous iliac crest has long served as the gold standard for anterior lumbar arthrodesis although added morbidity results from the bone graft harvest. Therefore, femoral ring allograft, or cages, have been used to decrease the morbidity of iliac crest bone harvesting. More recently, an experimental study in the animal showed that harvesting local bone from the anterior vertebral body and replacing the void by a radio-opaque beta-tricalcium phosphate plug was a valid concept. However, such a concept precludes theoretically the use of posterior pedicle screw fixation. At one institution a consecutive series of 21 patients underwent single- or multiple-level circumferential lumbar fusion with anterior cages and posterior pedicle screws. All cages were filled with cancellous bone harvested from the adjacent vertebral body, and the vertebral body defect was filled with a beta-tricalcium phosphate plug. The indications for surgery were failed conservative treatment of a lumbar degenerative disc disease or spondylolisthesis. The purpose of this study, therefore, was to report on the surgical technique, operative feasibility, safety, benefits, and drawbacks of this technique with our primary clinical experience. An independent researcher reviewed all data that had been collected prospectively from the onset of the study. The average age of the patients was 39.9 (26-57) years. Bone grafts were successfully harvested from 28 vertebral bodies in all but one patient whose anterior procedure was aborted due to difficulty in freeing the left common iliac vein. This case was converted to a transforaminal interbody fusion (TLIF). There was no major vascular injury. Blood loss of the anterior procedure averaged 250 ml (50-350 ml). One tricalcium phosphate bone plug was broken during its insertion, and one endplate was broken because of wrong surgical technique, which did not affect the final outcome. One patient had a right lumbar plexopathy that was not related to this special technique. There was no retrograde ejaculation, infection or pseudoarthrosis. One patient experienced a deep venous thrombosis. At the last follow up (mean 28 months) all patients had a solid lumbar spine fusion. At the 6-month follow up, the pain as assessed on the visual analog scale (VAS) decreased from 6.9 to 4.5 (33% decrease), and the Oswestry disability index (ODI) reduced from 48.0 to 31.7 with a 34% reduction. However, at 2 years follow up there was a trend for increase in the ODI (35) and VAS (5). The data in this study suggest that harvesting a cylinder of autograft from the adjacent vertebral body is safe and efficient. Filling of the void defect with a beta-tricalcium phosphate plug does not preclude the use of posterior pedicle screw stabilization.

Anterior reduction for cervical spine dislocation.

STUDY DESIGN: Retrospective analysis of a prospectively followed cohort. OBJECTIVE: Long-term evaluation of patients with anterior stabilization for dislocations of the cervical spine. SETTING: Level 1 trauma center. SUMMARY OF BACKGROUND DATA: Anterior stabilization of unstable cervical spine injuries is gaining popularity. However, the method of open reduction is controversial. METHODS: Forty-one consecutive patients with unstable dislocations/subluxations of the subaxial cervical spine were included. Closed reduction was attempted in all patients using Gardner-Wells traction. If this failed, an anterior open reduction was performed. Tricortical iliac crest autograft and anterior plating was used. Patients were assessed for: 1) rate of successful reduction and stabilization using only the anterior surgical approach; and 2) complications and long-term clinical and radiologic outcome. RESULTS: Two of eight (25%) anterior open reductions failed requiring posterior surgery. One of these patients had associated pedicle fractures with horizontal rotation of the lateral masses. All grafts had healed successfully at the most recent follow-up visit. Moderate neck discomfort was found in 5 of 41 patients. Significant neurologic improvement was observed. CONCLUSIONS: Most subluxations/dislocations of the subaxial cervical spine can be reduced using Gardner-Wells traction and successfully stabilized with anterior surgery alone. If closed reduction fails, anterior open reduction is successful in the majority of cases.

Anterior instrumentation for traumatic C1-C2 instability.

STUDY DESIGN: Technical note, case report. and review of literature. OBJECTIVE: Description of anterior transarticular internal fixation for traumatic C1-C2 instability. SUMMARY OF BACKGROUND DATA: The currently effective posterior approaches for instrumentation of the C1-C2 junction require considerable soft tissue dissection and prone patient positioning. Some medical and anatomic conditions restrict the posterior approach. MATERIALS AND METHODS: An odontoid screw and anterior transarticular C1-C2 screws were used to instrument an unstable injury at this junction. The lesion consisted of a type II dens fracture and C1 ring disruption. Two high-quality fluoroscopy machines, a radiolucent OSI fracture table, and the Synframe (Synthes, Paoli, PA) retraction system are used for this procedure. The implant of choice is the 4.0-mm cannulated titanium screw. RESULTS: At 4-month follow-up, successful stabilization without failure of hardware is documented. The patient's neurologic status is stable, with a minor residual left upper extremity motor deficit. The patient has restricted C-spine rotation but no neck pain with movement. CONCLUSION: Anterior stabilization through a standard Smith-Robinson approach of the C1-C2 junction with screws into the odontoid and the lateral masses of C1 is effective. Supine positioning and minimal soft tissue dissection are advantages of this method over standard posterior transarticular instrumentation. Knowledge of the local anatomy, strict adherence to the operative protocol, and high-quality fluoroscopy avoid potential surgical complications.